1. Non Muscular Anatomy Cervical Spine

2. Anatomy The neck is very complex anatomically… Joint anatomy and arthrokinematics is complicated Aims: Identify ligaments in the cervical spine and describe implications to practice Learn how joint orientation and arthrokinematics can be applied to your assessment, diagnosis and treatment (Hansen 2009)

3. Simplifying Ligament Anatomy

4. Ligament Anatomy Not all ligaments will be covered Discussion of ligaments that commonly have an implication on clinical practice NOTE: Ligaments themselves can be a nociceptive source of pain Certain ligaments are related to certain pathologies of the cervical spine (Hansen 2009)

5. Between Vertebral Bodies Anterior Longitudinal Ligament Supports the vertebral column and discs anteriorly The deep fibres connect adjacent vertebrae The superficial fibres extend across several vertebrae (Drake, Vogl et al. 2010)

6. Between Vertebral Bodies Posterior Longitudinal Ligament The deep fibres connect adjacent vertebrae posteriorly The superficial fires extend across several vertebrae Fibres only connect to the intervertebral discs and adjacent margins (Gray 1918)

7. Key Points Anterior Longitudinal Ligament Big and thick, therefore less likely to get an anterior disc bulge Posterior Longitudinal Ligament Considerably weaker than the anterior ligament Thicker over the intervertebral discs Not present posterolaterally Posterolateral disc bulges very likely due to lack of support from ligament (Sparks, Kelly et al. 2015)

8. Zygapophyseal Joint Ligamentum Flavum Passes from the laminae of adjacent vertebrae Present bilaterally of the laminae In cervical spine, the ligament is long, broad yet thin. (Magee 2008)

9. Key Learning Points Ligamentum Flavum Ossification or hypertrophy of this ligament can cause spinal stenosis Stenosis at this level can lead to cervical myelopathy Signs and symptoms of cervical myelopathy can include: Upper and/or lower limb pain weakness, sensation, reflex changes Clumsiness Neuropathic pain Gradually worsening symptoms Bladder or bowel dysfunction Difficulty walking for long distances Reduced fine motor skills and co ordination (ASI 2014)

10. Upper Cervical Ligaments

11. Atlantoaxial Joint Transverse Ligament of the Atlas Arising from the medial tubercles on the inner aspect of the arch of the atlas Prevents anterior translation of atlas on axis Anterior translation can cause compression of structures located in spinal canal (Drake, Vogl et al. 2010)

12. Atlantoaxial Joint Alar Ligament Passes obliquely superiorly and laterally from each side of the apex of the dens to the medial aspect of the occipital condyles Restricts excessive rotation of the atlantoaxial joint (Drake, Vogl et al. 2010)

13. Key Learning Points Alar Ligament and Transverse Ligament Ligaments stabilise atlantoaxial joint Hypermobility or rupture can occur at these ligaments, leading to instability Excessive movement can cause spinal cord compression If unstable, patients may report feelings of: Apprehension during neck extension A heavy head or head dropping off A lump in the back of the throat Cranial nerve signs and symptoms

14. Simplifying Joint Orientation & Arthrokinematics

15. Joint Orientation & Arthrokinematics Lots of stuff happens with movement Spinning, Rolling, Gliding, Opening, Closing, Squashing, Stretching Joint orientation and arthokinematic principles are very complex This course will cover key points that can inform assessment, diagnosis and treatment techniques For more detail read: Bogduk and Mercer 2000, Pal and Routal 2001, Loudon, Manske et al. 2013, Tsang, Szeto et al. 2013

16. Key Learning Points: C0 – C1 Orientation of occipital condyles and superior articular facets of the atlas (C0 – C1) allows mainly flexion and extension Consider C0-C1 dysfunction in flexion/extension is restricted (Surange 2010)

17. Key Learning Points: C1 – C2 50% of the rotation of cervical spine occurs at C1-2 This is due to the orientation of superior and inferior articulating facets which rotate around the dens If someone is restricted in rotation, consider C1-2 hypomobility (Mosby 2013)

18. Key Learning Points: C3– C7 Extension = closes facet joint and intervertebral foramen Flexion = opens facet and intervertebral foramen (Magee 2008)

19. Key Learning Points: C3– C7 Left Rotation = closes left intervertebral foramen and opens left facet Right Rotation = closes right intervertebral foramen and opens right facet Pain +/- referred pain with ipsilateral rotation part of the clinical prediction rule for cervical radiculopathy Decrease in side flexion & rotation = capsular pattern for OA; indicates arthritic facet joint. (ASI 2014)

20. Key Learning Points: T1 – T11 Significant interaction between thoracic and cervical spines (Tsang, Szeto et al. 2013; Heneghan and Rushton 2016 ) E.g decreased thoracic rotation can cause cervical spine dysfunction ALWAYS assess the thoracic spine in neck pain Recent Cochrane Review suggests that “Thoracic manipulation improves pain, function and quality of life” of those with neck pain (Gross, Langevin et al. 2015) (Drake, Vogl et al. 2010)

21. Key Learning Points –Summary C0 - C1 performs mainly flexion and extension C1 - C2 provides 50% of rotation available in cervical spine C3 – 7: Extension = closes facet joint and intervertebral foramen Flexion = opens facet and intervertebral foramen Left Rotation = closes left intervertebral foramen and closes right facet Right Rotation = closes right intervertebral foramen and closes left facet Pain +/- referred pain with ipsilateral rotation part of the clinical prediction rule for cervical radiculopathy Thoracic mobility can influence cervical movement and neck pain

22. Cervical Spine – Simplified 1.Rule out any Cervical Red Flags 2.Complete Structured Objective Assessment 3.Devise a Problem List 4.Treat: Do some talking therapy Do some hands on therapy Do some exercise therapy 5.Refer on where necessary.

23. Further Reading The articles below maybe of benefit for further reading Bogduk, N. and S. Mercer (2000). "Biomechanics of the cervical spine. I: Normal kinematics." Clin Biomech (Bristol, Avon) 15(9): 633-648. Loudon, J. K., R. C. Manske and M. P. Reiman (2013). Clinical Mechanics and Kinesiology, Human Kinetics. Pal, G. P. and R. V. Routal (2001). "The orientation of the articular facets of the zygapophyseal joints at the cervical and upper thoracic region." Journal of Anatomy 198(Pt 4): 431-441. Tsang, S. M., G. P. Szeto and R. Y. Lee (2013). "Normal kinematics of the neck: the interplay between the cervical and thoracic spines." Man Ther 18(5): 431-437.

24. References ASI. (2014). "Cervical Radiculopathy." Cervical Radiculopathy Retrieved April, 2016, from http://www.advancedspineboston.com/conditions/cervical-radiculopathy/. http://www.advancedspineboston.com/conditions/cervical-radiculopathy/ Drake, R. L., W. Vogl, A. W. M. Mitchell and H. Gray (2010). Gray's Anatomy for Students, Churchill Livingstone/Elsevier. Gray, H. (1918). "Anatomy of the Human Body." Twentieth. Retrieved April, 2016, from http://www.bartleby.com/107/.http://www.bartleby.com/107/ Hansen, J. T. (2009). Netter's Clinical Anatomy, Elsevier Health Sciences. Heneghan, N. R. and A. Rushton (2016). "Understanding why the thoracic region is the 'Cinderella' region of the spine." Man Ther 21: 274-276. Magee, D. J. (2008). Orthopedic Physical Assessment, Saunders Elsevier. Mosby (2013). Mosby's Medical Dictionary. St Louis, Missouri, Elsevier Health Sciences. Palastanga, N., D. Field and R. Soames (2006). Anatomy and Human Movement: Structure and Function, Butterworth Heinmann/Elsevier. Sparks, C., J. Kelly and G. Shankman. (2015). "Orthopedic Management of the Lumbar, Thoracic, and Cervical Spine." Retrieved May, 2016, from http://clinicalgate.com/orthopedic-management-of-the-lumbar-thoracic-and-cervical-spine/.http://clinicalgate.com/orthopedic-management-of-the-lumbar-thoracic-and-cervical-spine/ Surange, P. (2010). "Anatomy of Spine." Retrieved May, 2016, from http://www.slideshare.net/pankajnsurange/anatomy-of-spine.http://www.slideshare.net/pankajnsurange/anatomy-of-spine